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To investigate the effectiveness of double-balloon enteroscope-assisted retrograde cholangiopancreatography (DBE-ERCP) in patients with gastrointestinal surgically altered anatomy (SAA).From May 2013 to October 2021, all consecutive patients undergoing DBE-ERCP in three gastroenterological referral centers in Northern Italy were enrolled in the study. Patients were assessed regarding their medical history, previous surgery, time from previous surgery to the DBE-ERCP procedure, and the success or failure of DBE-ERCP.Fifty-three patients (60% men, median age 65 (23-89) years) undergoing 67 DBE-ERCP procedures (1-3 DBE-ERCP per patient) were enrolled. Reasons for SAA included orthotopic liver transplantation (23%), ulcers (15%), malignancies (43%), difficult cholecystectomy (17%), and other causes (2%). Types of surgery included Roux-en-Y biliodigestive anastomosis (45%), Roux-en-Y gastrectomy (32%), pancreaticoduodenectomy (17%), and Billroth II gastrectomy (6%). The overall DBE-ERCP success rate was 86%. The type of surgery, indications, and the length of time between previous surgery and DBE-ERCP were not statistically associated with DBE-ERCP success. The DBE-ERCP success rate increased from 2018 to 2021.DBE-ERCP is a successful procedure in challenging patients with SAA. The improvement in results over time indicates the necessity of adequate training and of centralizing patients in referral centers.

The primary aim of this study was to assess the reliability, intra- and inter-observer variation of the SPICE, Mucosal protrusion angle (MPA) and SHYUNG scores in differentiating a subepithelial mass (SEM) from a bulge.This retrospective multicentre study analysed the 3 scores, radiological studies, enteroscopy and/or surgical findings.100 patients with a potential SEM (mean age 57.6years) were recruited with 75 patients having pathology. In patients with a SEM the mean SPICE score was 2.04 (95% CI 1.82-2.26) as compared to 1.16 (95% CI 0.81-1.51) without any pathology (AUC 0.74, p0.001), with a fair intra-observer agreement (Kappa 0.3, p0.001) and slight inter-observer agreement (Kappa 0.14, p0.05). SPICE had a 37.3% sensitivity and 92.0% specificity in distinguishing between a SEM and bulge, whereas MPA90˚ had 58.7% and 76.0% respectively, with poor intra-observer(p = 0.05) and interobserver agreement (p = 0.64). The SHYUNG demonstrated a moderate intra-observer (Kappa 0.44, p0.001) and slight inter-observer reliability (Kappa 0.18, p0.001). The sensitivity of an elevated SHYUNG score (≥4) in identifying a SEM was 18.7% with a specificity of 92.0% (AUC 0.71, p = 0.002).Though these scores are easy to use, they have, at best, slight to moderate intra and inter-observer agreement. Their overall diagnostic performances are limited.

Background Suspected small bowel bleeding (SSBB) is the main indication for videocapsule endoscopy (VCE) and double balloon enteroscopy (DBE). We assessed the impact of both modalities in a large cohort of SSBB patients in a European tertiary center. Methods We retrospectively evaluated consecutive patients with SSBB undergoing VCE and/or DBE from March 2001 to July 2020. Demographic/clinical parameters, anticoagulant therapies, technical characteristics and adverse events were collected, as well as diagnostic yield (DY), VCE–DBE concordance, hemoglobin (Hb) values before and after DBE, and complications. Results 807 VCEs and 407 DBEs were performed in 751 patients. The DY was significantly higher in DBE compared with VCE (68.8% vs 57.7%), with the highest (75%) yield for overt active SB bleeding. The agreement between VCE and DBE was generally suboptimal (k = 0.059). This improved in cases where both procedures were done within 1–5 days of the other (k = 0.323). Post-procedural Hb values were significantly higher. In patients treated with direct oral anticoagulants (DOACs), there were no differences in DY, complications or Hb values compared with non-DOAC patients. Conclusion VCE and DBE play a pivotal role in the diagnostic and therapeutic approach to SSBB, having a high clinical impact even in patients treated with DOACs.

Background Small bowel capsule endoscopy (SBCE) has an established role in the management of refractory celiac disease (RCD) for the detection of complications. The aim of this study was to define the role of SBCE in the management of patients with RCD. Method Patients with histologically confirmed RCD who underwent successive SBCEs were recruited retrospectively from 2 tertiary centers. Results Sixty patients with RCD were included. The percentage extent of the affected small bowel (SB) mucosa improved on repeating a second SBCE in 26 patients (49.1%) (median 27.6% vs. 18.1%, P=0.007). Patients with RCD type II had more extensive disease than those with RCD type I on first (41.4% vs. 19.2%, P=0.004) and second (29.8% vs. 12.0%, P=0.016) SBCE. Patients with RCD type I tended to show a greater improvement in percentage of abnormal SB involved on repeat SBCE compared to those with RCD type II (P=0.049). Nine patients (15%) had RCD-related complications. Five patients developed ulcerative jejunoileitis, 3 patients developed enteropathy-associated T-cell lymphoma, and 1 patient developed cutaneous T-cell lymphoma. Conclusions SBCE can be a useful tool for monitoring the effects of treatment, primarily following its initiation. Patients with RCD type II have more extensive SB disease, equating to a more aggressive disease pattern.

Refractory celiac disease (RCeD) is a rare complication of celiac disease (CeD) with a severe prognosis. We describe a cohort of patients with RCeD, their clinical and histological features at diagnosis, after therapy and at lymphoma onset, and the rate and causes of death over a 17-year follow-up.We retrospectively enrolled RCeD-I and RCeD-II patients attending our center between January 2002 and October 2019. Medical data were collected at diagnosis and during monitoring. Response to therapy, changes in RCeD molecular markers, number of hospitalizations, discharge diagnosis, and cause and date of death were evaluated. The control cohort consisted of 1015 responsive CeD patients.Compared with RCeD-I, RCeD-II more frequently exhibits diarrhea (83 vs 64%), anemia (61 vs 50%), hypoalbuminemia (70 vs 21%), parenteral nutrition need (48 vs 7%), ulcerative jejuno-ileitis (7 vs 39%), and extended small intestinal atrophy (62 vs 21%). One RCeD-I and six RCeD-II patients developed lymphoma. Ten RCeD-II patients died, four from lymphoma progression. Among RCeD-II patients, atrophy extension was the only parameter correlated with hypoalbuminemia and mortality.Clinical severity, response to therapy, and mortality differ between RCeD-I and RCeD-II. Atrophy extension, evaluated at capsule endoscopy, was associated with disease severity and mortality.

Background Endoscopic ultrasound (EUS)-guided biliary drainage is becoming an option for palliation of malignant biliary obstruction. Lumen-apposing metal stents (LAMS) are replacing self-expandable metal stents (SEMS). The aim of this meta-analysis was to evaluate the efficacy and safety of LAMS and SEMS for EUS-guided choledochoduodenostomy (EUS-CDS). Methods A meta-analysis was performed using PRISMA protocols. Electronic databases were searched for studies on EUS-CDS. The primary outcome was clinical success. Secondary outcomes were technical success, reintervention, and adverse events. We used the random effects model with the DerSimonian–Laird estimation, and the results were depicted using forest plots. Subgroup analyses were also performed with data stratified by selected variable. Results Overall, 31 studies (820 patients) were included. The pooled rates of clinical and technical success were 93.6 % (95 % confidence interval [CI] 88.6 %–96.5 %) and 94.8 % (95 %CI 90.2 %–97.3 %) for LAMS, and 91.7 % (95 %CI 88.1 %–94.2 %) and 92.7 % (95 %CI 89.9 %–94.9 %) for SEMS, respectively. The pooled rates of adverse events were 17.1 % (95 %CI 12.5 %–22.8 %) for LAMS and 18.3 % (95 %CI 14.3 %–23.0 %) for SEMS. The pooled rates of reintervention were 10.9 % (95 %CI 7.7 %–15.3 %) for LAMS and 13.9 % (95 %CI 9.6 %–19.7 %) for SEMS. Subgroup analyses confirmed these results. Conclusions This meta-analysis showed that LAMS and SEMS are comparable in terms of efficacy for EUS-CDS. Clinical and technical success, post-procedure adverse events, and reintervention rates were similar between LAMS and SEMS use; however, adverse events require further investigation.

Inflammatory bowel diseases (IBD) affect the gastrointestinal tract: they include Crohn's disease (CD) and ulcerative colitis (UC). Each has a different phenotypic spectrum, characterized by gastrointestinal and extra-intestinal manifestations. People living with IBD are very interested in diet, but little is known about the impact of diet on these patients; no guidelines are available yet. In this review, we analyze the dietary patterns of patients with IBD and the approach to the choices of foods both in adults and pediatric patients. Very often, IBD patients report an intentional avoidance of gluten to manage the disease; furthermore, a proportion of IBD patients believe that dairy products worsen their symptoms and that avoidance may help the disease. They have a low compliance with the Mediterranean Diet, which is considered to have potential benefits but is little used in practice. In conclusion, the review underscores the pivotal role of nutritional counselling in IBD patients, and the importance of future clinical studies to evaluate the beneficial effects of dietary recommendations in the management of IBD.

We report a case of Strongyloides stercoralis suspected CNS dissemination in a Brazilian woman previously misdiagnosed with eosinophilic granulomatosis with polyangiitis and consequently treated with immunosuppressant therapies. This case highlights the urgent need for a broader awareness of NTDs among all specialists working in high-income countries with sustained migration flows.

Background and aim How symptoms and antibodies related to SARS-CoV-2 infection develop in patients with celiac disease (CD) is unclear. We aimed to investigate the impact of SARS-CoV-2 infection in CD patients. Methods CD patients were interviewed about the development of COVID-19 symptoms, compliance with anti-virus measures and adherence to a gluten-free diet (GFD). The presence of anti-SARS-CoV-2 IgG and IgA (anti-RBD and N proteins) was compared to that in non-CD subjects. Expression of the duodenal ACE2 receptor was investigated. When available, data on duodenal histology, anti-tissue transglutaminase IgA (tTGA), comorbidities and GFD adherence were analyzed. Results Of 362 CD patients, 42 (12%) reported COVID-19 symptoms and 21% of these symptomatic patients presented anti-SARS-CoV-2 Ig. Overall, 18% of CD patients showed anti-SARS-CoV-2 Ig versus 25% of controls (p = 0.18). CD patients had significantly lower levels of anti-N IgA. tTGA, duodenal atrophy, GFD adherence or other comorbidities did not influence symptoms and/or antibodies. The ACE2 receptor was detected in the non-atrophic duodenal mucosa of patients; atrophy was associated with lower expression of the ACE2 receptor. Conclusion CD patients have an anti-SARS-CoV-2 Ig profile similar to non-celiac controls, except for anti-N IgA. No risk factors were identified among CD parameters and GFD adherence.

Objective The SARS-CoV-2 pandemic has spread across the world causing a dramatic number of infections and deaths. No data are available about the effects of an infection in patients affected by celiac disease (CD) in terms of the development of related symptoms and antibodies. We aimed to investigate the impact of the SARS-CoV-2 pandemic in celiac patients. Design During a lockdown, the celiac patients living in the Milan area were contacted and interviewed about the development of COVID-19 symptoms as well as adherence to an anti-virus lifestyle and a gluten-free diet (GFD). They were also given a stress questionnaire to fill in. The development of anti-SARS-CoV-2 IgG and IgA (anti-RBD and N proteins) and the expression of the duodenal ACE2 receptor were investigated. When available, duodenal histology, anti-tissue transglutaminase IgA (tTGA), presence of immunologic comorbidities and adherence to the GFD were analysed as possible risk factors. Results 362 celiac patients have been interviewed and 42 (11%) presented with COVID-19 symptoms. The presence of symptoms was not influenced by tTGA positivity, presence of duodenal atrophy or adherence to GFD. 37% of the symptomatic patients presented anti-SARS-CoV-2 immunoglobulins (Ig). Globally, 18% of celiac patients showed anti-SARS-CoV-2 Ig vs 25% of the non-celiac control (p=0.18). The values of anti-RBD IgG/IgA and anti-N IgG did not differ from the non-celiac controls. Celiac patients had a significant lower level of anti-N IgA. The ACE2 receptor was detected in the non-atrophic duodenal mucosa of celiac patients; atrophy was associated with a lower expression of the ACE2 receptor. Conclusion CD patients have an anti-SARS-CoV-2 Ig positiveness and profile similar to non-celiac controls, except for anti-N IgA. The main celiac parameters and adherence to the GFD do not influence the development of a different Ig profile. What is already known about this subject? The SARS-CoV-2 pandemic has spread across the world causing infections and deaths. little is known about the possible relationship between autoimmune comorbidities and SARS-CoV-2 infection and COVID-19, and nothing it known about celiac disease. What are the new findings? In a large cohort of celiac patients living in a high SARS-CoV-2 incidence area in Northern Italy, no difference was observed evidenced in terms of the development of anti-SARS-CoV-2 Ig and their IgG and IgA profile compared with the normal population How might it impact clinical practice in the foreseeable future? The absence of a relationship between celiac disease and SARS-CoV-2/COVID-19 has a relevant impact on health policy to control the pandemic by supporting an optimal resource location.

Objective SARS-CoV-2 outbreak is spreading worldwide. As a consequence of the new circumstances, almost all endoscopic units underwent in-depth reorganization involving patients' selection. We analyzed the efficacy of the newly adopted endoscopic triage. Methods In March 2020, we monitored endoscopies to evaluate the effects of the novel selective triage aimed to reduce the number of investigations and viral spread/contagions. Clinical-demographic data of the patients, indications, type of endoscopy, endoscopic findings (subtyped in major and minor), finding rates (major and minor) and diagnostic yields (major findings) have been analyzed and compared to the endoscopic procedures performed in March 2019. Furthermore, patients were called at least 21 days after the endoscopy to evaluate the possibility of a Covid-19 onset. Results Accordingly to the novel triage, the number of procedures dropped from 530 to 91 (-84%). The finding rates and diagnostic yields were 83% (74-89) vs 71% (66-73) (P 0.015) and 56% (46-65) vs 43% (38-47) (P 0.03) on March 2020 and March 2019, respectively. A significant increase of operative procedures has been reported in 2020, 34% vs 22% in March 2019. All the patients were recalled and neither cases of onset of Covid-19 like symptoms nor positive nasopharyngeal swabs PCR have been evidenced. Conclusion The novel endoscopic triage significantly reduced the number of procedures and increased finding rates and diagnostic yields. However, a careful schedule of canceled procedures should be applied to avoid to miss relevant pathologies. No Covid-19 onset or infection has been noted after endoscopies.

A dramatic SARS-Cov-2 outbreak is hitting Italy hard. To face the new scenario all the hospitals have been re-organised in order to reduce all the outpatient services and to devote almost all their personnel and resources to the management of Covid-19 patients. As a matter of fact, all the services have undergone a deep re-organization guided by: the necessity to reduce exams, to create an environment that helps reduce the virus spread, and to preserve the medical personnel from infection. In these days a re-organization of the endoscopic unit, sited in a high-incidence area, has been adopted, with changes to logistics, work organization and patients selection. With the present manuscript, we want to support gastroenterologists and endoscopists in the organization of a "new" endoscopy unit that responds to the "new" scenario, while remaining fully aware that resources, availability and local circumstances may extremely vary from unit to unit.

Background & Aims Blue-light imaging (BLI) is a chromoendoscopy technique that uses direct (not filtered) emission of blue light with short wavelength (410 nm) to increase visibility of microvascular pattern and superficial mucosa. A BLI-based classification system for colorectal polyps (also called BLI Adenomas Serrated International Classification, BASIC) has been created and was validated using still images or short videos. We aimed to validate BASIC in a clinical practice setting, using thresholds recommended by the American Society for Gastrointestinal Endoscopy for the resect and discard strategy as the reference standard. Methods We studied 333 patients (mean age, 62.7±8.1 y; 176 men) who underwent screening colonoscopy from January through July 2019. Six endoscopists trained in BASIC participated in the study. All detected diminutive polyps were characterized by real-time BLI and categorized as adenoma or non-adenoma according to BASIC. All polyps were removed and evaluated by histopathology. The BLI-directed surveillance intervals (based on high-confidence characterization of polyps 5 mm or smaller and pathology feature for others) were compared with histology-directed surveillance intervals, according to United States Multi-society Task Force and European Society of Gastrointestinal Endoscopy recommendations. We calculated negative-predictive values of optical real-time analysis of diminutive rectosigmoid adenomas. Results When we applied BASIC, 748 polyps smaller than 5 mm were categorized with 89% accuracy (95% CI, 85.9%–90.6%). BLI-directed surveillance was correct for 90% of patients according to the United States Multi-society task force criteria (95% CI, 86%–93%) and for 96% of patients according to European Society of Gastrointestinal Endoscopy criteria (95% CI, 93%–97%). The negative-predictive value for 302 polyps smaller than 5 mm, located in the rectosigmoid colon and evaluated with high confidence, based on histologic features of adenomatous polyps, was 91% (95% CI, 85%–95%). Conclusions Our analysis of data from 333 patients undergoing screen colonoscopies supports the validity of BASIC discriminating diminutive colorectal polyps with histologic features of adenomas from non-adenomas. This allows for the implementation of the resect and discard strategy based on BLI in clinical practice. ClinicalTrials.gov no: NCT03746171.